Life Science Journal 2016; 13(1S) http://www.lifesciencesite.

com

Effect of Applying Nesting Technique as a Developmental Care on Physiological Functioning and

Neurobehavioral Organization of Premature Infants

Nahed Saied Mohamed El-Nagger and Orban Ragab Bayoumi

Pediatric Nursing, Faculty of Nursing, Ain Shams University, Egypt
E-mail: nahidalngar@yahoo.com

Abstract: Background: Premature infants are highly vulnerable group of the population. Premature births
accounts the highest mortality rate among infants in the first year of life. Behavioral organization is the infant's
ability to maintain a balance between autonomic/ physiologic, motor, state, attention and interaction, and self-
regulation by which the infant is in continual interaction with the infant's environment. Whereas, developmental
care are interventions taken to support the behavioral organization of each infant, promoting physiological
functioning, protecting sleep rhythms and enhancing growth and development. These interventions include
handling and positioning measures, reducing of stressful environmental stimuli, and cue based care.
Developmental positioning as nesting technique is a nursing skill used commonly in the developmental care of
premature infant. Whereas, this skill maintain premature infants in a comfortable position; enable spontaneous
motor activity for skeletal joint and neuromuscular function and facilitate the monitoring of stable vital signs.
Aim: Evaluate the effect of applying nesting technique as a developmental care on physiological functioning and
neurobehavioral organization of premature infants. Design: A quasi-experimental study was utilized. Setting:
The study was carried out in the Neonatal Intensive Care Unit (NICU) at Maternity and Gynecological Hospital
affiliated to Ain Shams University Hospitals. Subjects: A purposive sample consisted of eighty premature
infants were chosen from previously mentioned hospital and was divided into two similar groups (study and
control). Tools: Three tools were used; Premature Infants Assessment Sheet (PIAS), Neonatal Behavioral
Assessment Tool (NBAT) andNeonatal Infants Pain Scale(NIPS). Results: There were high statistical significant
differences concerning premature infants' physiological, behavioral and neurological outcome as regards
temperature, oxygen saturation (SaO2), infant's crying, sleeping, motor activity and primitive reflexes between
study and control groups. Conclusion: Applying nesting technique as a developmental care had a positive effect
on physiological functioning, and neurobehavioral organization of premature infants. Recommendations:
Emphasize on the importance of applying nesting technique for all premature infants in the NICUs as standard of
developmental care and further research for implementing a training program for all neonatal nurses regarding
applying nesting technique as a developmental care to improve their quality and proficiency of care for
premature infants.
[Nahed Saied Mohamed El-Nagger and Orban Ragab Bayoumi. Effect of Applying Nesting Technique as a
Developmental Care on Physiological Functioning and Neurobehavioral Organization of Premature
Infants. Life Sci J 2016;13(1s):79-92]. ISSN 1097-8135 (print); ISSN 2372-613X
(online) http://www.lifesciencesite.com. 9. doi:10.7537/marslsj1301s1609.

Key Words: Nesting Technique, Developmental Care, Physiological Functioning, Neurobehavioral

Organization, Premature Infants.

1. Introduction Preterm birth affected about 1 of every 10

Prematurity is a term used for all neonates
born less than 37 week's or 259 days of their
gestation and is consider the direct cause for 24%
of neonatal deaths. Whereas, the rates of preterm
birth have been reported to range from 5-7% of
live births in some developed countries and are
estimated to be substantially higher in developing
countries.[1]
In 2005, it was estimated that 9.6% of all
births were preterm, which means that about 12.9
million births known as preterm. Nearly 85% of
this burden was in Asia and Africa, where 10.9
million births were preterm. About 0.9 million
preterm births occurred in Latin America while,
0.5 million in North America and the same
number also in Europe, In developing countries,
usually complete and accurate data of population
and medical records do not exist.[1, 2]
infants born in the United States. Preterm birth
rates decreased from 2007 to 2014. But, more
recent data indicate a slight increase in the national
preterm birth rate from 2014 to 2015. In 2015, the
rate of preterm birth (PTB) among African-
American women (13%) was about 50 percent
higher than the rate of preterm birth among white
women (9%).[2, 3]
In Egypt, the number of preterm births at 32
weeks to <37 weeks were 123.131 and in Kingdom
of Saudi Arabia (KSA) were 41.728and this
statistic may indicates the high admission hospital
rate to Neonatal Intensive Care Units (NICUs)
every year. According to statistics of WHO, the
rate of PTBis 17% worldwide and 27% in
industrialized and developing countries.[4, 5,6]
An estimated 15 million babies are born
preterm and this number is rising every year, that is
more than one in ten babies. In 184 countries, the

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 Life Science Journal 2016; 13(1S)
rate of PTB ranges from 5% to 18% of born babies,
almost 75 percent of them could save with current
cost-effective interventions. Each year, one million
children die due to PTB complications. Many
survivors face along lifetime disability, as learning
disabilities in addition to hearing and visual
problems.[5,7]
Prematurity is the leading cause of death
among children under the age of five years.
Moreover, in countries with reliable data, rates of
PTB rates are increasing. In low-income countries,
half of the babies born at or < 32 weeks die due to
a lack of cost-effective care, such as breastfeeding
support, warmth and basic care for breathing
difficulties and infections, meanwhile, in high-
income countries, almost all of these babies are
survive. [3,8]
Premature infants are particularly a
vulnerable group who require advanced medical
interventions, and highly specialized nursing care
in order to thrive and survive. Whereas, their early
birth interrupts the maturity of their lungs, gut,
brain and immune system, this lack of development
interferes with the most basic function of airway
control and breathing, impacts digestive ability,
jeopardizes brain function and impairs immune
function. In addition, their lack of self-regulatory
behaviors, inability to make purposeful movements
and lack of communication abilities leave them
extremely vulnerable.[7,9]
Developmental care is the using for range of
nursing and medical interventions to decrease the
preterm neonate's stress in NICUs. However,
premature infants have to work hard grow and get
better, also they need help.[8,10] Developmental care
help premature infants to focus energy on growing
and getting better. Thus, developmental care in
NICU is becoming a worldwide standard. This
concept is a comprehensive approach in which
caregiving is based on the individual infant's
behavior and refers to the impact of the NICU on
the infant’s environment and their family.[9,11]
Developmental care aspects include
positioning and handling of the infant.
Observations of NICU procedures have shown that
a preterm infant when handled for reasons such as
feeding, hygienic care, for therapeutic or diagnostic
procedures, can negatively react for several
minutes until becoming exhausted. This results in
an unnecessary expenditure of energy that can, at a
later time, turn into physiological (tachycardia,
bradycardia, apnea and drop in the oxygen
saturation (SaO2) or behavioral instability (fatigue,
difficulty in sleeping and flaccidity) pain and signs
of distress.[9,11]
However, meta-analysis evaluated the effects
of different elements of developmental care and
concluded that more consistent effects of specific
interventions, such as a postural support, on short-
and long-term clinical outcomes were required.[3,11]
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Nesting technique is a nursing skill used
commonly in the developmental care of premature
infant. Use of rolled-up sheets to form a ‘nest’ to
provide physiological, behavioral and postural
stability to the preterm infant. Whereas, nesting is
one key factor in maintaining a beneficial position
for a premature infant through position hands
together near face and feet together by using
positioning aids to provide a safe snug and
supportive nest. Nesting skill maintain premature
infants in a comfortable position; enable
spontaneous motor activity for skeletal joint and
neuromuscular function and facilitate the
monitoring of stable vital signs.[3,9,11]
The environmental challenges that premature
infants face can affect their wholeness and during
their adaptation to extra uterine life, these threat
scan be minimized by implementing appropriate
nursing interventions that aiming for conserving
and promoting wholeness.[7,12]
Although, developmental positioning or
developmentally supportive positioning is not a
standardized care. Studies have shown that,
premature infants who receive developmental
positioning through applying nesting technique by
placing simple sheet rolls to provide supports and
boundaries, they can feel something protective
around them and stay in hospital for less time in
addition gain weight better.[3,13]
The preterm infant requires support to
facilitate and maintain postures that enhance motor
control, physiological functioning and reduce
stress. Indeed, the developmental positioning goals
are to; provide flexion in the limbs and trunk and
facilitate of midline skills, also assist in infant's
self-regulation and maximize infant stability,
preserve energy, growth, and promote
neurobehavioral organization.[14, 15]
Nesting positioning directly impacts, the
amount of energy the infant expends in several
ways. Whereas, infants who are handled and
positioned properly; cry less, have fewer
behavioral indicators of pain, prevents fluctuations
in cerebral blood flow and prevent the fragile blood
vessels in the brain from rupturing, also facilitates
ventilation and help in preventing trauma to the
airways, which aid in the prevention of chronic
lung disease. [3,10, 16]
Behavioral organization is the infant's
ability to maintain a balance between autonomic/
physiologic, motor, state, attention and interaction,
and self-regulation by which the infant is in
continual interaction with the infant's
environment.[8,16]
So that, during the nesting technique the
premature infant’s reaction should continuously
monitored for any adverse behavioral or physical
signs, such as heart rate, Oxygen saturation (SaO2),
and respirations using pulse oximeter device and
cardiac monitor.[13,16]
 Life Science Journal 2016; 13(1S)
Positioning the infant with a midline
orientation, providing appropriate boundaries and
support to promote physiologic flexion should be a
major goal, and these interventions directly
influence the goal of minimizing musculoskeletal
damage. [17, 18,19] Furthermore, responding for
premature infants' behavioral cues and providing
slow gentle handling that promotes flexion can
decrease their stress level as well as promote trust
atmosphere for the infant. In addition, minimizing
pain and discomfort by properly positioning and
handling decrease stress and promote positive
neurological maturation. [20,21]
The role of NICU nurse is vital applying of
developmental care successfully and the provision
of an optimal NICU environment. Nursing notes
should assessed daily weight gain, numbered of
bowel movement and medications measured in the
morning shift on the preceding night shift by the
nurses and calculated by two methods: one method
was the average of premature infant's daily weight
gain and the second method was the average of
premature infant's weight gained in the NICU state.
Observation of sleep/awake states are useful for
evaluating the development and neurobehavioral
organization of preterm..[22, 23]
Neonatal nurses are central in NICUs efforts
to improve quality of care. Comforting
interventions in the field of nursing care will
contribute to high neonatal outcomes and
eventually will lead to hospital development.
Nursing curriculum also should be equipped with
the recent advances in neonatal care and students
should also be trained to provide developmental
care in an NICU setting. Nurse administrators
should provide and recommend the interventions
like Nesting in the setting like NICU of the
hospital.[3 ,23]
Significance of the Study
Nesting technique (Developmental
positioning)is an intervention to improve
musculoskeletal and postural outcomes, promote
physiological functioning and sleep states of
premature infants. So, developmental positioning is
an essential skill for NICU nurses.[3,24] The benefits
of developmental positioning are evident in the
literature, but less known about how NICU nurses
learn about it. There is a disconnect between what
is practiced in some NICUs and what is known in
the evidence; however developmental positioning
is effective in improving premature infant's
outcomes, less is known about how to improve the
nurses' proficiency for providing developmental
positioning in the care of premature.[ 25,26,27]
Aim of the Study
The aim of this study was to evaluate the
effect of applying nesting technique as a
developmental care on physiological functioning
and neurobehavioral organization of premature
infants.
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Research Hypothesis: This study hypothesized
that:
1. Applying nesting technique as a developmental
care in the different positions for premature
infants has a positive effect on their
physiological functioning and neurobehavioral
organization.
2. Prone position is the most appropriate position
for premature infants in both nesting and un-
nesting groups.
2. Subjects and Methods
A. Research Design: The study design was a
quasi-experimental.
B. Research Setting:
This study was carried out in the Neonatal
Intensive Care Unit (NICU) at Maternity and
Gynecological Hospital affiliated to Ain Shams
University Hospitals. Whereas, this setting has a
high capacity of premature infants.
C. Research Subjects:
Sample size and characteristics:
 A purposive sample consisted of eighty
premature infants were chosen from the
previously mentioned hospital and was divided
into two similar groups (study and control).
 Group one: It was the study group, 40
premature infants were positioned through
applying nesting technique by using simple
linen rolls to provide boundaries and support in
the three different positions ; supine, side- lying
and prone.
 Group two: It was the control group,40
premature in fants werepositioned
throughusingthe routine positions (routine care)
in the three different positions (supine, side-
lying and prone) without applying nesting
technique.
Inclusive criteria:
 All premature infants from both gender.
 Gestational age 32-≤36 weeks.
 Birth weight 1500 - ≤ 2500 grams.
 They delivered in the hospital through both
Normal Vaginal Delivery (NVD) and Cesarean
Section (CS).
Exclusive criteria:
 Premature infants whom were suffering from
severe RDS and on mechanical ventilation.
 Premature infant with congenital anomalies or
infection.
D. Tools of Data Collection
I. Premature Infants Assessment Sheet (PIAS):
It was designed by the researchers and it was used
to collect data about the premature infants
including; infants' gender, gestational age,
diagnosis, type of delivery, birth weight,
duration of hospital stay and premature infants'
weight at discharge,..,etc .
II. Neonatal Behavioral Assessment Tool
(NBAT): It was adapted from Als, et al. (2005)
 Life Science Journal 2016; 13(1S)
and Als, (2009)[28,29] The required
modifications were carried out according to the
nature and aim of the study. It was used to
assess the premature infants' behavior. Through
assessing their ability to keep a balance
between the following five subsystems:
1. Autonomic: Assessing the basic physiologic
functioning indicators of premature infants such as:
temperature, respiratory rate (RR), heart rate (HR),
SaO2 through using the pulse oximeter and cardiac
monitor in addition to tremors/startles and skin
color.
2. Motor: look at the premature infant's motor
tone, movement activity and posture.
3.States:Categorizing the premature infants'
neurobehavioral or central nervous system
arousalandthe sleep/awake states of the infant (i.e.,
deep sleep, light sleep, drowsy, alert, hyper alert,
and cry).
4.Attention/Interaction: Assessing the premature
infants' continuum state (deep sleep to cry) as
alertness to interaction.
5.Self – Regulatory Behavior: Assessing the
premature infants in maintaining a balanced,
relatively stable and relaxed state of subsystem of
functioning or in returning to this a state of
subsystem functioning, if imbalance or stress has
occurred.
III. Neonatal Infant's Pain Scale (NIPS): It was
adopted from Waldemar, et al (2015) [30] It was
used to assess quality and sensitivity of pain for
the premature infants. NIPS consisted of four items
namely; Face, Leg, Cry, and Activity. Accordingly,
the severity of pain was classified into three
categories as the following:
 Score from 0-2 referred to no or mild pain.
 Score from 3-4 referred to mild to moderate
pain.
 Score >4 referred to severe pain.
Validity and Reliability:
Expert’s validity for study tool based on
feedback from five panel experts from academic
and clinical fields: one professor of pediatric
medicine, two associate professors of pediatric
nursing and neonatologist in addition to assessing
content validity by both internal consistency and
test-retest reliability that was very good. Whereas,
internal consistency (Cronbach’s alpha)
coefficients for study tools were between 0.83 to
0.90.
Phases of Study Application:
1. Preparatory phase
A review of the past, current local and
international literature covering all study aspects
through using journal, books and magazines done
to be suitable with research problem and guide the
researchers in preparation of study tools.
2. Exploratory phase
A. Pilot study:
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It was conducted on 10% of the study sample
(8 premature infants; 4 premature infants in both
study and control groups) to examine the clarity,
feasibility and applicability of the study tools, and
time require to fill out it. The required
modifications were done through adding or
omission of unneeded criteria before data
collection according to the results of the pilot
study. The pilot study subjects were excluded from
the sample of the study.
B. Field work:
The field work was started at the beginning of
July to the end of August 2015. The researchers
were available four days weekly in the High risk
and Intermediate NICUs from 8am –2 pm. The
number of premature infants assessed daily were 3-
4. The researchers filled out the study tools by
themselves and the times required for filling out of
each tool was around 5-10 minutes.
C. Procedures Technique:
I. Procedures for (study and control ) both
groups of premature infants:
 Selecting the premature infants in relation to
inclusion and exclusion criteria, and through
using PIAS.
 Classifying the premature infants randomly in
either study and control groups through serial
numbers of cases, whereas the premature
infants who had single numbers were chosen in
the study group (Nesting positioning) while, the
premature infants who had double numbers
were chosen in the control group (Un -Nesting
positioning).
II. For study group (Nesting positioning)
 Performing nesting technique after full
explanation the aim of study to the bedside
nurses, and obtaining heir verbal agreement.
 Preparing and arranging all the required nesting
equipment from the NICU such as; linen,
blanket, small pillow….etc.
 Making the nest by folding the blanket form
one corner, then placing it upright and laying
the linen over the blanket.
 Positioning the premature infant inside the nest
in the three positions (supine- side-lying and
prone position respectively).
 Ensuring that the nest size is suitable for the
infant's body, not too loose and not too tight
during each position.
 Position the premature infant first in supine
position through wrapping infant with hand to
midline the nest through putting small pillow
under the infant's shoulder to keep airway open.
 Changing the premature infant's position after
two hours to side- lying (left or right)position
through supporting the infant's back by the nest
or small pillow and ensure put both the infant's
hands together near to the face.
 Changing the premature infant's position after
two hours to prone position through supporting
 Life Science Journal 2016; 13(1S)
the infant by small pillow under the chest to
keep the airway open.
 Assessing the premature infant's physiological
functioning and neurobehavioral organization
three times in each position every20 minutes
daily until discharge through using NBAT.
Also, to eliminate the effect of position change,
the premature infants were assessed after stabi-
lization period approximately, 15 minutes in
each position.
 Documenting all findings in the NBAT and
NIPS including:
- Infant's physiological functioning such as vital
signs (Temp., HR, RR) occurrence of apnea
and SaO2.
- Infant's behavioral response such as sleep/a
wake states and deep sleep to crying.
- Infant's motor activity and primitive reflexes.
- Infant's pain level during invasive procedures
such as; nasogastric tube insertion or blood
sampling and cannulation technique.
III. For control group (Un-Nesting
positioning):
 Putting premature infant in the three positions
(supine- side-lying and prone positions
respectively), without nesting, two hours for
each position and assess the effect of applying
different positions without nesting technique on
premature infants health outcomes during each
position through using the study tools daily till
discharge.
 Assessing the premature infant's physiological
functioning and neurobehavioral organization
three times in each position every20 minutes
daily until discharge through using NBAT.
Also, to eliminate the effect of position change,
the premature infants were assessed after stabi-
lization period approximately 15 minutes in
each position.
 Documenting all findings in the NBAT and
NIPS including:
- Infant's physiological functioning such as vital
signs (Temp., HR, RR) occurrence of apnea
and SaO2.
- Infant's behavioral response such as sleep/a
wake states and deep sleep to crying.
- Infant's motor activity and primitive reflexes.
- Infant's pain level during invasive procedures
such as; nasogastric tube insertion or blood
sampling and cannulation technique.
IV.For both study and control groups (Nesting
and Un-Nesting positioning)
- Weighing the premature infants at discharge
from the NICU to evaluate the infant's weight
gain.
- Documenting the duration of premature infants'
hospital stay.
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Administrative Design
Permission for data collection was obtained
from the hospital and NICU manager in the
previously mentioned setting through submitting
an official letter.
Statistical Design
The data collected, organizing, revised,
tabulated and analyzed by using the SPSS Version
(20). Numerical data was expressed as mean ± SD,
while qualitative data expressed as frequency and
percentage for both groups. Statistical test as Chi-
square (X 2 )used for determining statistical
significant differences between (Nesting and Un –
Nesting groups) study and control groups.
Statistical significance differences was as at P-
value < 0.05 and highly statistically significant
differences was considered at P- value <0.01, and
no statistical significant differences was considered
at P. value >0.05.
Ethical Considerations
 A verbal consent obtained from the mother or
parents of each premature infant before
inclusion in the study sample.
 An official oral permission was obtained
through the appropriate channels before data
collection.
 Clear and simple clarifications about the nature
and aim of the study to the NICU managers and
mothers.
 Code number for premature infants applied to
protect their confidentiality.
Limitations of the study
 Lack of nurses' awareness about the importance
of applying nesting technique to the premature
infants.
3. Results
Regarding the premature infants'
characteristics, table (1) showed that 52.5% & 47.5
% of premature infant's gestational age was 34 -
≤36 weeks in both study and control groups
respectively. Meanwhile, 47.5% and 42.5% of
premature infants' birth weight was 1500- < 2000
grams in study and control groups respectively
with the mean score of premature infants' birth
weight was 1748 ± 425.88 grams in study group
compared to 1718±235.11 grams in control group.
Also, regarding the duration of hospital stay, this
table revealed that 27.5% of premature infants in
the study group was 3-<6 days compared to
52.5%of them in control group their duration of
hospital stay was ≥10 days. Also, this table
clarified that 55% and 45% of premature infants
gaining weight <50 gram sat discharge in study and
control groups respectively, and minority (5%) of
premature infants in study group did not gain
weight compared to32.5% of them in control
group.
 Life Science Journal 2016; 13(1S) http://www.lifesciencesite.com

Table (1): Percentage Distribution of Premature Infants According to Their Characteristicsin

Both Groups
Total Number 80
Premature Infants' Study Group Control Group
Characteristics No.40=100% No.40=100%
No. % No. %
I. Gestational Age (weeks)
< 32 8 20 10 25
32 - < 34 11 27.5 11 27.5
34 - ≤ 36 21 52.5 19 47.5
II. Birth Weight (grams)
1500 - < 2000 19 47.5 17 42.5
2000 - < 2500 10 25 13 32.5
≥ 2500 11 27.5 10 25
Mean ± SD 1748 ± 425.88 1718±235.11
III. Duration of Hospital Stay (Days)
<3 7 17.5 5 12.5
3-<6 11 27.5 5 12.5
6 - <10 13 32.5 9 22.5
≥10 9 22.5 21 52.5
IV. Weight Gain at Discharge(Grams)
< 50 22 55 18 45
50 - < 100 11 27.5 7 17.5
≥ 100 5 12.5 2 5
No weight gain 2 5 13 32.5

Figure (1): revealed that 55% of the premature
infants' gender were girls, and the rest (45%) of
them were boys.
Figure (2) showed that 62.5% of the
premature infants delivered through cesarean
section (CS) and the rest (37.5%) of them by normal
vaginal delivery (NVD).
Regarding the premature infants' physiological
functioning, table (2) demonstrated that 90%,97.5%
&85% compared to 40%, 60% &0% of premature
infants their temperature was normal in supine,
side-lying and prone positions in study and control
groups respectively that indicated statistical
significance differences (X2=23.14,20.57 & 14.06 at
P-values 0.00, 0.00, &0.00 ) respectively. As
regards respiratory rate, this table also revealed that
80% of premature infants compared to 57.5% of
them had normal respiratory rate during supine
position study and control groups respectively that
referred to statistical significant difference
(X2=5.33, at p-value 0.05). As regards SaO2 during
prone position, it was found that 100% and 90% of
premature infants had SaO2level at ≥ 95%in both
study and control groups respectively.
Regarding premature infants' behavioral
responses in the form of sleep/awake states, table
(3) represented that 82.5% , 87.5% & 100% were
having deep sleep during supine, side-lying and
prone positions compared to20%,20% &10% in
both study and control groups respectively. This
table also demonstrated that 80% and 90% of
premature infants' a wake state were alert in study
group compared to 62.5% and 30% of them in
control group duringside-lying and prone positions
respectively that reflected statistical significance
differences (X2=21.37 &10.14,at P-values 0.00,
0.006 ) respectively. Minority (5%) of premature
infants in study group were crying during prone
position. Also, there were statistical significant
differences (X2=17.86& 25.78at P-values
0.00&0.00 ), concerning behavioral responses as
regards infants' sleep/a wake state between study
and control groups in the three positions
respectively.
Table (4) clarified that 92.5 %,85%& 97.5%of
premature infants were having positive motor
activity in study group compared to 62.5% , 52.5%
and 77.5% in control group during supine, side-
lying and prone positions respectively that indicated
a high statistical significance differences
(X2=10.32,13,27&7.31at P-values 0.001,
0.00&0.007 ) respectively. As regards premature
infants' primitive reflexes, this table represented that
85% , 77.5% &95% of them were having positive
primitive reflexes compared to 37.5%,45% &67.5
% during supine, side-lying and prone positions in
both study and control groups respectively. As
regards premature infants' attention/interaction, this
table also clarified that 70%,80%,&95% of them
had positive attention/interaction responses in study
group compared to 50%,55%, and 60% of them in
control group during supine, side-lying and prone
positions respectively. Also, there was statistical
significant difference (X2=13.61 at P-value 0.00)
between study and control groups regarding
premature infants' self – regulatory behavior.

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 Life Science Journal 2016; 13(1S) http://www.lifesciencesite.com

Regarding premature infants' pain level , table differences (X2=14.08,24.06&30.97 at P-values

(5) revealed that 82.5%,70 % & 77.5% of premature
infants were having no or mild pain in study group
compared to 47.5% , 20 % and 17.5% in control
group during supine, side-lying and prone positions
respectively that explained statistical significance
0.00, 0.00&0.00 ) respectively. Meanwhile, 2.5% of
premature infants were having severe pain
compared to 35%of them during side-lying position
in both study and control groups respectively.

Fig. (1): Percentage Distribution of Premature Infants Fig. (2): Percentage Distribution of Premature Infants
According to their Gender According to their Mode of Delivery

0 37.5%
55 % 45 % 62.5%

Vaginal
Boy
C.S.
Girle

Table (2):Percentage Distribution of Premature Infants According to their Physiological Functioning in Both
Groups
I. Temperature
Study Group (No.=40) Control Group (No.=40)
Hypothermia Normal Hyperthermia Hypothermi Normal Hyperthermi
Positions > 36.5 C0 36.5 - 37.2 ˃ 37.2 C0 a 36.5 - 37.2 a X2 P -value
C0
> 36.5 C0 C0 ˃ 37.2 C0
% % % % % %
Supine 2.5 90 7.5 47.5 40 20 23.14 0.00*
Side - lying 0.0 97.5 2.5 52.5 60 80 20.57 0.00*
Prone 0.0 85 15 0.0 0.0 0.0 14.06 0.00*
X2 (P- value)
35.89 (0.00*)
II. Heart Rate
Normal Tachycardia Normal Tachycardia
Positions 120 – 150b/m >150 b/m 120 – 150 b/m >150 b/m X2 P-value
% % % %
Supine 87.5 12.5 57.5 42.5 9.20 0.00*
Side - lying 85 15 77.5 22.5 0.738 0.39
Prone 82.5 17.5 77.5 22.5 0.313 0.57
X2 (P- value) 5.48 (0.14)
III. Respiratory Rate
Bradypnea Normal Tachypnea Bradypnea Normal Tachypnea P- value
Positions >35 c/m 35 – 50 c/m 50˃ c/m >35 c/m 35 – 50 c/m 50˃ c/m X2
% % % % % %
Supine 5 80 15 5 57.5 37.5 5.33 0.05*
Side - lying 2.5 87.5 10 2.5 70 27.5 4.20 0.08
Prone 17.5 72.5 10 5 72.5 22.5 4.52 0.08
X2 (P- value)4.30 (0.56)
IV.Oxygen Saturation (SaO2)
Positions ≥ 95% > 95% ≥ 95% >95% P- value
% % % % X2
Supine 82.5 17.5 60 40 4.94 0.02*
Side - lying 70 30 65 35 11.25 0.00*
Prone 100 0.00 90 10 4.21 0.04*
X2 (P- value) 13.17 (0.00*)
*p-value <0.05 statistical significant differences; p-value ˃ 0 .05 No statistical significant differences.

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Table (3): Distribution of Premature Infants According to Their Behavioral Responses in Both Groups
1.Infants' Sleep State
Study Group (No.=40) Control Group (No.=40)
Positions Deep light Drowsy Deep light Drowsy X2 P-value
sleep sleep sleep sleep
% % % % % %
Supine 82.5 10 7.5 20 30 50 9.44 0.002*
Side - lying 87.5 7.5 5 20 25 55 11.86 0.001*
Prone 100 0.0 0.0 10 15 75 11.42 0.001*
X2 (P-value) 17.86 ( 0.00*)
1I. Infant's Awake State
Alert Hyper Cry Alert Hyper Cry
Positions Alert Alert X2 P-value
% % % % % %
Supine 75 5 25 67.5 10 22.5 19.03 0.00*
Side – lying 80 10 10 62.5 7.5 30 21.37 0.00*
Prone 90 5 5 30 10 60 10.14 0.006*
X2 (P-value) 25.78 (0.00*)
*p-value <0.05 , statistical significant differences; p-value ˃ 0 .05 No statistical significant differences.

Table (4): Distribution of Premature According to their Motor Activity, Attention/ Interaction and Self –
Regulatory Behavior in Both Groups
1. Motor Activity
Study Group (No.=40) Control Group (No.=40)
Positions Positive Negative Positive Negative X2 P-value
% % % %
Supine 92.5 7.5 62.5 37.5 10.32 0.001*
Side - lying 85 15 52.5 47.5 13.27 0.00*
Prone 97.5 2.5 77.5 22.5 7.31 0.007*
2
X (P-value) 16.36 ( 0.00*)
1I.Primitive Reflexes
Study Group (No.=40) Control Group (No.=40)
Positions Positive Negative Positive Negative X2 P-value
% % % %
Supine 85 15 37.5 62.5 19.01 0.00*
Side - lying 77.5 22.5 45 55 9.97 0.002*
Prone 95 5 67.5 32.5 9.92 0.003*
2
X (P-value)17.46 (0.00*)
III. Attention/ Interaction
Study Group (No.=40) Control Group (No.=40)
Positions Positive Negative Positive Negative X2 P-value
% % % %
Supine 70 30 50 50 19.01 0.00*
Side - lying 80 20 55 45 9.97 0.002*
Prone 95 5 60 40 9.92 0.003*
X2 (P-value) 16.67 (0.00*)
IV. Self-Regulatory Behavior
Study Group (No.=40) Control Group (No.=40)
Positions Balance Imbalance Balance Imbalance X2 P-value
% % % %
Supine 70 30 55 45 18.09 0.00*
Side - lying 75 25 60 40 13.11 0.00 *
Prone 90 10 70 30 9.02 0.003*
X2 (P-value) 13.61 (0.00*)
*p-value <0.05 , statistical significant differences; p-value ˃0 .05 No statistical significant differences.

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Table (5): Distribution of Premature Infants According to their Pain Levelin Both Groups
Infant's Pain Level
Study Group (No.=40) Control Group (No.=40)
Positions No/ Mild Mild/Mod Severe No/ Mild Mild/Mod Severe X2 P-value
Pain Pain
% % % % % %
Supine 82.5 17.5 0.0 47.5 40 22.5 14.08 0.00*
Side – lying 70 27.5 2.5 20 45 35 24.06 0.00*
Prone 77.5 22.5 0.0 17.5 60 22.5 30.97 0.00*
2
X (P-value) 36.18 (0.00*)
*p-value < 0.05 statistical significant differences; p-value ˃0 .05 No statistical significant differences.

4. Discussion adequacy of neonate's intrauterine growth, whereas

Prematurity has been one of the major causes
of neonatal mortality and morbidity NICUs
worldwide and is considered the second cause of
neonatal mortality after congenital anomalies, and a
major specification of neonatal
morbidity. Worldwide, PTB affects 11.1% of all
pregnancies. Preterm infants are at higher risk for
acquiring complications that result from either
functional or anatomic immaturity (Al-Qurashi, et
al.(2015).[6]
Nesting positioning is a key factor in
maintaining a beneficial position for the neonate
usually it let the infants feel more secure and are
more physiologically stable if they have boundaries
(nesting) that placed around them, as they are used
to an enclosed womb. Also, they gain comfort from
being able to grasp their hands together, suck their
fingers or hold onto bedding(Warren,
2015).[14]Therefore, the main aim of this study was
to evaluate the effect of applying nesting technique
as a developmental care on physiological
functioning and neurobehavioral organization of
premature infants.
Concerning the characteristics of premature
infants, the current study demonstrated that
approximately half of the premature infants'
gestational age was 34 -≤36 weeks and slightly less
than half of them their birth weight was 1500- <
2000 grams in study and control groups. In this
context Prasenjit et al. (2015)[24] mentioned that the
birth weight is an indicator of the neonate's health
status. Also, Vaivre-Douret, and Golse (2015)
[25]
stated that the relation between the neonates'
gestational age and birth weight reflects the
the organ systems maturity depends on gestational
age. So, the grater gestational age infant the fuller
developed the organ systems. Additionally, PTB are
associated with higher rates of low birth weight
(50.5%) compared to full term births and increased
13 times with premature deliveries(Al-Qurashi, et
al.,2015).[6]
Regarding the duration of hospital stay of
premature infants, the results of the current study
represented that slightly more than one fourth of
premature infants in the study group their duration
of hospital stay was 3-<6 days compared with more
than half of them in control group their duration of
hospital stay was ≥10 days. As regards the
premature infant's weight gain at discharge, it was
found that approximately half of them were gaining
weight <50 grams in study and control groups and
minority of them in study group did not gain weight
compared with nearly one third of infants in control
group. These results were in accordance with Cole,
and Gavey (2011)[22]who mentioned that the effect
of nesting position application is helping in
promoting calming and comfort of the infants, so it
could maintains weight gain. Meanwhile, Prasenjit
et al.(2015) [24] reported that all the existing trials of
various developmentally supportive care programs
have shown positive results for the infants and
families and none have found any negative effects.
Furthermore, most of the studies that have been
conducted taken short-term outcome measures at
discharge as their outcome measures include
reduced hospital stay (World Health
Organization, 2015). [12]

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On studying the autonomic subsystem of
behavioral organization. Regarding the premature
infants' physiological functioning, the results of the
current study revealed that the majority of
premature infants in study group with nesting
positioning compared with nearly half of them in
control group without nesting positioning their
temperature was normal during supine, side-lying
and prone positions respectively with statistical
significance differences between study and control
groups. These results were consistent with Gibbins,
et al. (2010) (21)who mentioned that prone position
can increase time of sleep and decrease energy
expenditure compared to supine. Whereas, the
surface area is greatest in supine and therefore
greater heat loss. Thus, the use of nesting with high
boundaries can also help reduce heat loss. Nesting
and ambient heating can be adjusted to achieve both
comfort and warmth (McCall , et al.,2 010).[18]
In contrast to Lewis, et al. (2013) (27)who
reported thatone of studies has been done for the
developmental care including the developmental
positioning, but it could not explored the benefits of
each care.
The results of the current study indicated that
there was no statistical significant difference
regarding the heart rate between study and control
groups (Nesting and Un-Nesting Positioning) in the
three different positions (Supine, Side-Lying and
Prone). Nevertheless, there were high statistical
significant differences between study and control
groups during supine position as regards respiratory
rate and heart rate respectively. The present study
results were confirmed with Prasenjit et al.(2015)
[24]
who pointed out that preterm infant's
positioning is a basic nursing care in the NICU that
includes head up tilted, supine, side-lying and prone
positions. Meanwhile, these results were
contradicted with Picheansathian, et al. (2009)
(19)
who reported that prone position can improve
lungs and cardio-respiratory development and
facilitate improvement of respiratory status. Studies
have reported a different premature infant's
outcomes that affected bydifferent positioning as
prone positionthat have many advantages for
premature infants. (Gibbins, et al.,2010).[21]
In contrastKihara,(2013)[33]observed the
effect of nested and swaddled positioning supportof
very low birth weight infants (VLBWI) in the prone
position on their sleep distribution,heart rate, and
behavior state. A total of 20 VLBWI who were
born at a gestational age of 26.5 ± 4 weeks with a
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birth weight of 709 ± 207 g were studied at an
average gestational age of 37.4 ± 0.6 weeks and a
weight of 1590 ± 337 g. The study concluded that a
prone position with nested and swaddled
positioning support facilitate sleep and heart rate
stability compared to prone positioning alone.
As regards SaO2of premature infants in prone
position, the results of the current study
demonstrated that all premature infants had SaO2
level ≥ 95% compared to very few of them in both
study and control groups respectively. Regarding
respiratory rate of premature infants, the results of
the present study also revealed that the majority of
premature infants compared with slightly more than
half of them had normal respiratory rate in supine
position. However, there was no statistical
significant difference between study and control
groups regarding respiratory rate in prone and side-
lying positions respectively. These results were in
agreement with Prasenjit, et al. (2015) [24] who
pointed out that the trials of various
developmentally supportive care programs have
shown positive results for the infants through
improving lung and neuro-physiological
functioning.
On investigating the behavioral responses of
premature infants in the form of sleep/a wake state,
the results of the present study showed that the
majority of premature infants were alert during
prone position in study group compared to slightly
more than one fourth of them in control group .
Additionally, all premature infants were had deep
sleep in prone position in study group (Nesting
positioning group) compared to three quarters of
them incontrol group. Minority of premature infants
were crying during prone position in study group
compared to two thirds of them in control group.
There were a high statistical significant differences
regarding the crying and sleeping in the three
positions namely, supine, side-lying, prone
respectively. Results of the present study were
consistent with the study of Baley (2015) (31) who
concluded that developmental positioning was
associated with a longer quiet sleepduration and
better sleep organization.
Furthermore, Ludington-Hoe, et al.(2006)(32)
who studied the neurophysiological assessment of
neonatal sleep organization in preterm infants
exhibit decreased sleep and decreased arousal
during developmental positioning , and suggesting
more mature sleep organization. Moreover,
Grenier, et al.(2015)(23) who stated that preterm in-
 Life Science Journal 2016; 13(1S)
fants spendmore time quiet, a sleep and less time
awake in the prone position, in addition to
organized sleep-wake cyclist .
In contrast, Cole, and Gavey (2011)(22) who
emphasized that behavior ratio did not differ
between prone un-nested and prone nested, nor
between supine un-nested and supine nested. More
self-regulatory and stress behaviors were related to
longer periods of fussing and crying. Longer
periods of light sleep were related to fewer stress
behaviors. Infants performed the fewest stress
behaviors in prone nested, prone un-nested, or side-
lying nested. These positions may benefit infants in
the NICU by reducing the need for motor-based
self-regulatory behaviors and potentially conserving
energy for growth.
On studying the effect of applying nesting
technique as a developmental care on motor activity
and primitive reflexes of premature infants, the
results of the current study revealed that there were
high statistical significant differences related to
infants' motor activity and primitive reflexes in the
three different positions (Supine, side-lying, prone)
and between nesting and un-nesting groups
respectively. The results of the present study were
supported by Prasenjit, et al.(2015) (24) who
emphasized that, regular changes in a premature
infant’s posture may have a beneficial effect on
development that is shown in a better response to
psychomotor and neurological assessments, less
excitability, and movements that are easier to elicit.
So, promoting a functional posture in these infants
is a mean of promoting correct psychomotor and
neurological outcomes.
In this context, Vaivre-Douret, and Golse,
(2015)(25) pointed out that preterm infants positioned
in alternative positions during NICU hospitalization
and demonstrated less asymmetry by term
equivalent age, compared to infants positioned with
traditional positioning methods. When infants
placed in a single position for a long period,
muscular shortening quickly develops, which
disrupts functional motor organization. Also,
Ferrari, (2007)[34] conducted an experimental study
to evaluate the movement and posture in preterm
during supine position in and outside the nest. The
findings showed that nest promotes wrist
movements, facilitatesa flexed posture of the limbs
with adduction of shoulders and movements
towards and across the midline and reduces frozen
postures of the legs and arms.
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Concerning the effect of applying nesting
technique on premature infants' attention/
interaction and their self- regulatory behavior. The
results of the current study revealed that there were
high statistical significant differences between study
and control groups regarding premature infants'
attention/ interaction and their self – regulatory
behavior. These results were in accordance with
Grenier, et al. (2015)(23) who emphasized that there
was a statistically significant relationship between
infant position and self-regulatory and stress
behaviors. The side-lying un-nested position
showed to be the position where the highest number
of self-regulatory behaviors occurred; the fewest
number occurring in the prone nested position.
Whereas, the high number of stress behaviors seen
in the side-lying un-nested position; the lowest
number was seen in the prone nested position.
Whereas, Prasenjjit, et al.(2015).[24]reported
that the prone position is most favorable, with prone
un-nested and side-lying nested positions coming in
second, for improved state of arousal control (based
on occurrence of stress behaviors and self-
regulation) in preterm infants. Supine or lateral
decubitus positions to increase psychomotor and
neurobehavioral outcomes and in prone or lateral
decubitus positions to improve self-regulation.
As regards the premature infants' pain level
according to NIPS, the results of the current study
clarified that approximately three fourths of
premature infants experienced no or mild pain
compared to half of them in study and control
groups respectively. Meanwhile, minority of
premature infants compared with less than one
fourth of them experienced severe pain in study and
control groups respectively; however there were
high statistical significant differences between study
and control groups in the three positions. These
results were consistent with Grenier, et al.(2015)
(23)
who pointed out that although only one research
article studied the effects of positioning alone for
decreasing procedural pain, the multi-interventional
study included positioning as one of the
components examined. Whereas, prone positioning
promotes deep sleep in preterm neonates; however,
this effect does not provide a sufficient analgesic
effect during painful procedures and concluded that
prone positioning did not decrease pain in neonates.
Therefore, neither of the studies provided evidence
to support that prone positioning decreases pain
response in preterm neonates.
 Life Science Journal 2016; 13(1S)
Also, Comaru, and Miura (2009)[10] were
performed a study to determine the effects of a
postural support on the behavioral and physiological
stability of preterm infants while during a diaper
care. All infants appeared increased pain score
levels and distress during diaper care. This was
significantly less for babies nested compared with
non-nested babies (P<0.0001).It was concluded that
applying postural support during diaper care
reduces the signs of pain and distress and.
Accordingly, Halverson,(2010) (9) pointed out
that developmental care positioning promotes
normal postural and musculoskeletal development,
maintains patent airway, and promotes thermal
regulation. Premature infants who have
developmentally positioning cry less, have less
flailing of their extremities and fewer behavioral
indicators of pain, have improved physiologic
outcomes and sleep states.
Conclusion
Applying nesting technique as
developmental care had a positive effect on
physiological functioning, and neurobehavioral
organization of premature infants. Whereas, there
were statistical significant differences between
applying nesting positioning technique and normal
thermoregulation for premature infants ,increase
oxygen saturation, deep sleep, less crying, with no
or mild pain level, balanced self – regulatory
behavior, and positive motor activity and primitive
reflexes. Also, increasing weight gain at discharge
and Lessing the duration of hospital stay compared
to premature infants' health outcomes whom had
un- nesting positioning. Meanwhile, there were no
statistical significant differences between applying
nesting technique in relation to the respiratory rate
and heart rate of premature infants. Furthermore,
prone position was the most appropriate and
favorable position followed by side- lying position
for both nested and un-nested groups premature
infants.
Recommendations:
1. Emphasize on the importance of applying
nesting technique for all premature infants in the
NICUs as standard of developmental care.
2. Further research: Implementing a training
program for all neonatal nurses regarding
applying nesting technique as a developmental
care to improve their quality and proficiency of
care for premature infants.
http://www.lifesciencesite.com
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